<!DOCTYPE html>
<html>
<head>
	<title>广州中医药大学金沙洲医院</title>
	<meta charset="utf-8">
	<link rel="stylesheet" type="text/css" href="/templets/breastII/css/pages/online.css">
	<script src="http://code.jquery.com/jquery-1.11.1.min.js"></script>
	<script type="text/javascript" src="/templets/breastII/js/pages/online.js"></script>
</head>
<body>
	<div class="appointment_div">
		<form id="myform" method="post" action="http://mail.jszjrzk.com/breast/pc">
			<div class="input_div">
				<div class="word">
					<label>
						<span>*&nbsp;</span>
						姓名：
					</label>
				</div>
				<input type="text" id="name" name="name" placeholder="请输入您自己的姓名">
				<div class="word">
					<label>性别：</label>
				</div>
				<input type="radio" name="sex" id="sex man" checked value="男">
				男
				<input type="radio" name="sex" id="sex woman" value="女" >
				女
				<br>
				<div class="word">
					<label>
						<span>*&nbsp;</span>
						联系电话：
					</label>
				</div>
				<input type="text" name="phone" id="phone" placeholder="请输入您自己的电话号码">
				<div class="word">
					<label>年龄：</label>
				</div>
				<input type="number" name="age" placeholder="请输入您自己的年龄">
				<br>
				<div class="word">
					<label>医师预约：</label>
				</div>
				<select id="doctor" name="doctor">
					<option value="赵为国">赵为国</option>
					<option value="戴晓江">戴晓江</option>
				</select>
				<div class="word">
					<label>预约时间：</label>
				</div>
				<input type="date" id="date" name="date">
				<input type="time" id="time" name="time">
				<br>
				<div class="word desc">
					<label>病情描述：</label>
				</div>
				<textarea id="desc" placeholder="请输入您自己的病情" name="desc"></textarea>
				<div class="err-msg"></div>
				<div class="btn_div">
					<div class="sub_btn btn">
						<img src="/templets/breastII/images/yuyue_01.jpg">
					</div>
					<div class="reset_btn btn">
						<img src="/templets/breastII/images/yuyue_02.jpg">
					</div>
				</div>
			</div>
		</form>
	</div>
</body>
</html>